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WORKERS'COMPENSATION DECLARATION � � �� �
I hereby affirm that I have a cartifimte of consent io self 92-000s ovw sis� � � � .� � �
insure,or a cerfifimte of Workers'Compensafion Ins�rance,or �6A699D � .�
a cer�ified copy�hereof,(Sec.3800,L,�j�, �y/� ���°�B � - �� � � .APPLICATfON FOR PERMIT � � � -
PolicyN W 7D�i'rS��ny_ ��7e�3G7/�`f.i�1.Q /IT✓� ..�s . . .� �. � :.., .
❑Certified copy is hereby fur�;5ned. . .. SEWER - SEWAGE DISPOSAL . � � �- - �
�.Certified copy Is filed with the coumy b ilding inspection ..��COUNTY OP LOS ANGELES BUILDING AND SAFETY: � ' ' ""
depart �, �� � ����y-�
Da�e � �f i��"�4pplicam FOR APPLICANT TO FI L IN CONNECTION DATA
CER�FICATE OF EXEMPTION fROM WORKERS'
COMPENSATION INSURANCE �DfDRE55 (j'.�f,(q/'� sranoN �EPTH
(This section need noi be completed if the work involved by the / MaNHo�E REFERENCE ucaee
' peimit is far one hundred dollars�$700)or less.) �ocnutr �` �,Ssr(/ G-- tOWER '
I certif th0� in the erformance Of ihe WOfk f0�whlCh fh15 NEARESi TVPEOFCONNECTION LENGTHFROM �
Y P CRO55 ST. (f J Y. CURB v.L. M.l.TO P.L. �
permii is issued,I shall not employ any person in any monner ec No.
so as to become sobject to ihe Workers'Compensation Lows. . , pwNPR ���� - / ca innP n10, �os No Q(;1 f
DaiB Applicont A�DRE55 ✓���JQ��/ .�3,� TRUNKPFRMITNO. ROA�PEHMIiNO_ q'Zb%,�+'� .
NOTICE TO APPUCANT: If, ofter makln ihi5 Certificate Of� t,(� -� "l'1G,_� (3 AFFIDAVII 'JJANER EASEMENi NECORD.INSTR.NO. DAiE '
9 GIiY �.Y TEL.NO ��Z) ✓.��
Exemption, you should become subject fo the Workers'� tE�Ai
� Compensation provisions of the Lobor code,you most forthwi�h. oescaiarioN ioirvo. Hwv.oesT.wioeNiN�
� comply with such provisions or Ihis perrqit shall be deemed �
.o„�bo�l � o�n.� .�.�,
LICENSED CONTRACTORS DECIARATION V v rdo oF e�ocs. e�RMn�No.V��.�,������
. SRE OF LOT NOW ON LOT �
I hereby affirm that I am licensed under provisions of Chapter� . use or '�_.__ .__ _
-�-�9(commencing wilkSection 7000)of DiJision 3 of the B�si-; ouimiNcs �HARGE$ '
� ness and Professions Code,and my license is in ful�force and�.
L'Ff2[�. . �f� _ ('pNTRACTOR �'t'%' ��� � GONNEGTION CHARGE FLE Y .
//'
� License Num�b/er' C CIa55 ADDRE55 � REIMBURSEMENT fEE a
Coniractor�f�' �+�� � � �ci NO GRoua M.4F PROCESSEo ev p �
f� i I ' ��� r �� � QTY �� /LC.S� iEL.NO. � � 'i('"�� AK PG ) �' .
LJ I am exempt under Sec. of t e LA.Ca. ucETnEise No. anss (,� �r�1S�� V O
Plum6ing Code and/or Sec. of ihe N� DESCRIPTION OF WORK Yee riNat � U
HOUSE SEWFR CONNECTING TO UA(E W
� B.&P.Code for the following reason PUBLiC SEWER VALIDATION . �
�PTIC TANk,SEEPAGE PIT OR � �
7175AND/ORDRAINFIFLp b+AL .;�'
� ......... "_"_._ ..
- HOlISF SEWER GONNECTING 70
/ PRIVATE�ISPOSAL SVSiEM
' $IOIIOIUfe �/� , � �•' CONNECi AD�IiIONAt BLDG-OR , ' ,
OWNER- UILDER DEC�ARATION woaK ro House sewre
.I herz6y affirm that I am exempi from the Contracior's License EO%RFLC�'SSPWLGURYWF.LRAMANI OLC
Law for ihe following reason(Secton 7D31.5,Buisness and Pro- atiER,R6PAiR oa nenNooN HousE
� feSSlOnS COfIe�: SEWER OR p15POSAI gSYS�i/EM��
, �i,as owner of the propertv,or my employees with waaes as �YNZt�-C� , ��
their sola compensation,will do the work and ihe sfructure .
is nat infended or offered for sole(Section 7044,Business r� �l%,,F,�'•, �
' and Professions Code). OWNER'$ PCrmit g -� �
� �.
I,as owner of the properry,am exdusively mmrocting with AUTHORIZATION TOTAL FEE ;� v'7j '�° " " '�°
licensed coniractors to construct fhe project(Section 7�44, I HqyE AT iN15 DAiE A CONIRACi WITH THE HEREIN NAMCD C NTRACTOR i0 f h .I v 1��`\ �
. BI/SInC55 a�CI PfOfE5510f15 COCIe�. � CONNECT iHE ABOVE UESCRI9EU EXISTING�WFLIING TO THE PU6LIC SEWER. x� �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a tonstruction'lending agency SIGNED THIS �AY OF 19_ , °V "' � v��,t;ti�
for the performance of �he work for which this permit is ��'`'NE°oR
issaed(Sec 3097�ClV,C.�. OWNENSAGENI U��(�_,���
FlDDRCSS
Lender's Name
Lender's Address '
I certify�that I have read ihis applica�ion and state that the
above informafion is correct.I agree to comply with all Coonty ,
�ordinances ond$tate laws regulafing Plum6ing and Sewers,
and hereby authorize representatives of this Coumy ta en�er , �
upon the qbo -mentioned roperiy for inspection pos q. . '
,�����- ����--
SignalU e o Permiitee Dof SEE REVERSE FOR EXPLANATORV LANGUAGE
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